Chiropractors have protested in the comment threads that we have an outdated, biased view of chiropractic, and that modern chiropractic practice is very different. They claim that they have rejected the original basis of chiropractic (the subluxation/nerve interference/innate paradigm), that they reject all forms of quackery, that what they do is based on scientific evidence, and that they have an important role to play in modern health care. We think that “reformed” attitude is rare. We would love to know what percentage of chiropractors fall into the “reformed” category, but no studies have been done to answer that question. Now there is a new study from Australia that provides important information about the state of chiropractic practice in that country. While it can’t answer the question about the number of “reformed” chiropractors in the US, it does shed some light on the subject.

The broken neck accusation: Unanswered questions

First, a brief review of the broken neck accusation. A chiropractor treated a 4-month-old baby with torticollis (wry neck), the baby developed a loss of head control after the treatment, and a subsequent x-ray was interpreted as showing a “hangman’s” fracture. A review commissioned by the Australian Health Practitioner Regulation Agency (AHPRA) and carried out by the Chiropractic Board of Australia (CBA) found that the baby did not have a broken neck, but rather a congenital defect called spondylolysis, where certain areas of the vertebral arch are absent, leaving a defect that can look similar to a fracture. The review found that the chiropractor did not cause a fracture, but it found other problems with his history-taking and examination of the child and with his record-keeping. The case against the chiropractor was closed after he agreed to get further education. No explanation was ever offered for the baby’s loss of head control; the chiropractor who wrote the report thought it was unrelated to the treatment.

Here the story gets murkier. The pediatrician who treated the infant stood by his original diagnosis. He said that the baby had both a fracture and a congenital defect (that the chiropractor had overlooked), that the congenital defect put the child at greater risk of fracture and complicated the baby’s treatment for the fracture, and that a follow-up CT scan done 6 months later showed new bone formation that confirmed the diagnosis of a healing fracture. The AHPRA report and a later review by an unnamed “internationally renowned” radiologist insisted that no fracture had occurred. But apparently the consensus of the baby’s doctors was that it had, since last week the Friends of Science in Medicine newsletter reported that the baby spent six months in a neck brace.

Michael Vagg wrote an account of the whole kerfuffle. The AHPRA report was inappropriately leaked to the public. This was a massive failure on the part of the CBA, which must maintain confidentiality in order to protect the integrity of future investigations. The Chiropractor’s Association of Australia (CAA) protested loudly, demanding retraction of the news story and claiming that no child had ever been injured by chiropractic (a demonstrably false claim).

With no resolution of the conflicting radiologic interpretations, and with the other unanswered questions, we can only speculate about what really happened.

The COAST study

The new study is titled “Chiropractic Observation and Analysis Study (COAST): providing an understanding of current chiropractic practice.” It was published in The Medical Journal of Australia in November, 2013. The eight authors included medical professors, chiropractors, ethicists, and statisticians. The full text is available online.

Method

It was a cross-sectional study using the established BEACH (Bettering the Evaluation and Care of Health) methods. 180 chiropractors in Victoria, Australia were randomly chosen from the register and 52 eventually completed the study (a satisfactory response rate). Female chiropractors were under-represented, but otherwise the respondents were similar to the general population of chiropractors. They were asked to record details of 100 patient encounters by hand on paper forms, and they were given a $200 honorarium as an incentive. A total of 4,464 patient encounters were recorded. The forms documented several things:

Demographic characteristics of chiropractors

Demographics and health profiles of patients

Reasons patients gave for seeking chiropractic care

Problems and diagnoses identified

Care provided

Selected results (numbers rounded):

Characteristics of chiropractors (see Box 1)

The mean number of patient care hours a chiropractor worked in a week was 27, spread over a mean of 6 clinic sessions

The mean number of patients seen per week was 84

Patient characteristics (see Box 2):

58% of patients were women

44 patients were under the age of one year (1% of total encounters), 3% were age 1-4 and a total of 9% of patients were under the age of 15

Information on age spread, language, ethnicity, and occupation was reported

Source of payment: patient 81%, health insurance 46%, plus a very small percentage paid by workers compensation and other sources

Other information: median duration of encounter 15 minutes (range 11-20), follow-up recommended in 85% of encounters, patient referred by another patient 52%, referred by a GP 4%, referred to a GP 3%

Techniques used (Box 4)

Explanation: Activator = a hand-held spring-loaded device that delivers and impulse to the spine, drop piece = chiropractic table where a section of the patient’s body can be quickly lowered, blocks = wedge-shaped blocks placed under the pelvis, chiro system = includes applied kinesiology, sacro-occipital technique, and neuroemotional technique, flexion distraction = a treatment table that flexes in the middle for traction and mobilization of the lumbar spine

Comments

Infants and children only represent 1% and 9% of chiropractic patients, but even that is too many, since there is no evidence that children benefit from chiropractic treatment and there is a risk of injury.

Chiropractors are often thought of as “back specialists” but less than half of visits are for back problems.

About 10% of visits are for non-musculoskeletal problems. There is no evidence that chiropractic is effective for non-musculoskeletal problems.

“Health maintenance” was listed for 4.24% of encounters. It wasn’t clear how many of these visits were for maintenance adjustments. There is no evidence that maintenance adjustments provide any benefit to patients. There is controversy among chiropractors about whether “chiropractic wellness care” should be an integral part of their practice.

The category of “spinal problems” included an unspecified number of chiropractor-recorded diagnoses of “chiropractic subluxations” without a definition of what that meant. Most chiropractors no longer believe there is a bone out of place and use the word to mean dysfunction rather than displacement. It would be better if the term “subluxation” was no longer be used at all, since “no supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention” and “the subluxation construct has no valid clinical applicability.” In other studies, 98% of chiropractors believed that “most” or “many” diseases were caused by spinal misalignments and over 75% of chiropractors believed that subluxation contributed to 50% or more of visceral disorders like asthma or colic. The present study really doesn’t tell us anything about Australian chiropractors’ beliefs; it only tells us what diagnoses they wrote down.

There is cause for concern in the treatments listed. Activator methods are not supported by evidence. Half of American chiropractors in a 1991 survey said they used them, but the percentage in this study appears to be much lower, around 20%. The use of “chiro system” appears to be around 12%, but that is worrisome since the methods that includes are all bogus: applied kinesiology, sacro-occipital technique, and Neuro Emotional Technique (NET). The study showed that 5% of chiropractors recommended supplements, but it did not specify which supplements were recommended, so we have no way of knowing if any of the recommendations were evidence-based.

Conclusion

This new study doesn’t tell us what percentage of chiropractors try to follow science-based principles, but it offers some hints that will have to do until a study is done to address that question directly. It tells us that a substantial number of chiropractors use quack methods, and the ones who do obviously can’t be science-based. It tells us that children are being treated with chiropractic in the absence of any evidence that it is effective. It suggests that these Australian chiropractors are not trying to act as family doctors or primary care gatekeepers, as some American chiropractors do. It doesn’t indicate that Australian chiropractors are trying to treat diabetes, as some American chiropractors have been doing. The study leaves many questions unanswered and raises some new ones; and it doesn’t provide any evidence to support the claims that chiropractic is being “reformed.” Preston Long thinks it hasn’t been and can’t be reformed from the inside; and if it could, it would no longer be “chiropractic.”

53 thoughts on “Chiropractic Reform: Myth or Reality?”

“[The new breed of chiropractors] claim that they have rejected the original basis of chiropractic (the subluxation/nerve interference/Innate paradigm),”

Fine. Let’s say for a moment that this is true. What then do chiropractors bring to the table? Physical therapists have the physical therapy under control. Medical doctors have the medicine under control. What precisely does this new breed of chiropractors who don’t believe in chiropractic bring to the medical armamentarium??? It seems that they have whittled a peg and are now trying to find a hole in which it will fit.

If you want to be a doctor go to medical school. If you want to be a PT get a degree in physical therapy. But what is the rationale for going to chiropractic school if you don’t believe in chiropractic?

About the only logic is insurance companies seem to be more apt to pay for chiropractic. For whatever reason, chiropractic seems to operate with impunity in the eyes of insurance where as PT is viewed as witchcraft.

If you can find a chiropractor that knows that he is just a glorified PT and treats accordingly, there tend to be fewer hoops to jump through to get insurance to cover it.

“ While spinal manipulation therapy (SMT) is an effective option for treating certain types of low back pain,…”

Is it? Is it any better than standard medical treatment? Any better than doing nothing?

If you look at the Palmer Chiro school website, it tells you absolutely nothing about what they actually study, in direct contrast to real universities which list their coursework and describe course content. It seems the entire thing (chiropractic) is a farce so one wonders how it could be “effective” at anything at all?

Actually – they do have some basic descriptions on their website. An example:

“A philosophic exploration of the evolution of the hypotheses describing the subluxation complex and its application to matters of health and illness will be undertaken. The major hypothesis of chiropractic, the subluxation complex, will be discussed in depth. The student will become conversant with the history of subluxation terminology and the current status of some of the major hypotheses pertaining to the subluxation complex. Also to be presented are causes and prevention of the subluxation, with clinical examples presented where relevant.”

I love that Chrome flags subluxation as a misspelled word and the top suggestion is sublimation.

As a side note – here’s the problem often not addressed is how to transition those doing science-based “chiropractic” really are doing physical therapy. If that’s the case, we should discuss more in detail ways to get them converted to physical therapy. They did still do lots of schooling, most of it good. They still have something to contribute. What do we do with those who want to convert – let’s give them a way to do so.

while you have the time, take a look at what Physical Therapist learn in school. It far exceeds manipulations and exercise. Chiro learn a business plan on how to make the patient believe you need them to be healthy, PT’s empower patients on how to stay healthy and pain free, so they don’t have to come back. Good and bad exist in both fields, but there is no way you can compare a PT from a post-graduate degree program from an accredited university to a Chiro trade school, not ever affiliated with a university and does not require an undergraduate degree. They just require you to be over 21 years of age and can pay the bill. if you go to one expect to be chronically in pain and forever in treatment.

As a chiropractor that views his profession the way many of you do, I would love more of this type of discussion. The career path I chose was expensive and largely non-evidence based. I studied the work of Janda and focus on normalizing abnormal muscle movement patters with exercise rehabilitation. The patient leaves with the tools to maintain their own health, not to return for “wellness check ups”. The path to PT being easier and less expensive would help the “good” chiropractors leave and quackery would be easier to be distinguished for the public an other medical practitioners looking to refer patients for this type of treatment option.

SMT is equivalent in effectiveness to standard medical treatment for back pain, not superior. It may offer somewhat earlier temporary relief in some cases, but the final outcome is the same. It is a perfectly reasonable option for someone who prefers several visits to a chiropractor’s office to taking pills or doing nothing but following their doctor’s advice.

Harriet,
That is quite an accurate summation. It is alarming, though, how many patients with a simple non-specific mechanical low back pain, or an acute sprain, or a muscular spasm, who have been to see their doctor, and all the treatment they were recommended was “bedrest for two weeks” and a prescription of Panadeine Forte or Endone. This is without a physical examination and no plans for followup following initial pain relief.

And, to be clear, I am not attempting a tu-quoque here either, though it could be construed this way.

Anybody who treats low back (or neck) pain, or anybody, really, should be aiming to do better to treat within an evidence based model.

I agree. Two weeks bedrest is clearly contraindicated and is not the standard of care. And no one should be prescribing narcotics without seeing the patient. If you know of someone who practices that way, you could file a complaint with the medical board.

Any research on low back pain that does not indicate that the subjects were put into homogeneous groups based on their symptoms is not valid and interpretation of outcomes are guess work. Not all low back pain has the same etiology and therefore, cannot be treated the same way. Manipulations alone only provide and analgesic affect that lasts about 4 hours, it is the same as taking a pill. Neither will help in prevention of re-occurrence. Neither address the problem that provoked the insult, they just treat the symptoms. Physical therapists have a broader knowledge base on how to treat and prevent all non-specific conditions.

Harriet Hall wrote: “[SMT] …is a perfectly reasonable option for someone who prefers several visits to a chiropractor’s office to taking pills or doing nothing but following their doctor’s advice.”

But is it? According to Prof. Edzard Ernst the risk/benefit profile for SMT for chiropractic LBP patients isn’t favourable due to the lack of standardisation within the profession:

Quote
“Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them (11). And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment.”

@Blue Wode, Of course I agree with you. I should have qualified my “perfectly reasonable” to “perfectly reasonable as long as the patient is fully informed of the risk/benefit ratio and chooses to accept the risk; and as long as the chiropractor is one who rejects subluxation nonsense, limits his practice to short-term evidence-based treatment of musculoskeletal conditions, eschews all the woo-woo, does not manipulate the neck, and does not offer maintenance adjustments. Quackwatch and other sources have useful tips for choosing a chiropractor. http://www.quackwatch.com/01QuackeryRelatedTopics/chirochoose.html

Only 52 chiropractors actually finished the survey. That number might be OK if it were a somewhat random selection, but that was only 33% of the 156 chiropractors who were asked to do it (about half said no, and another 20 dropped out after agreeing). That’s a large non-random exclusion which could be hiding a lot of complete cranks who knew that this sort of survey might not look good.

Also, 39 out of 100 “patient encounters” are listed as maintenance/wellness/checkup as the reason for their visit…

Musculoskeletal reasons for encounter were described by patients at a rate of 60 per 100 encounters (95% CI, 54–67 encounters) and maintenance and wellness or check-up reasons were described at a rate of 39 per 100 encounters (95% CI, 33–47 encounters).

That might sound good, as chiropractic is nonsense as preventive or diagnostic care.

However, unless there is a lot of overlap among the other “problems managed”, it could very well be that people with no unusual symptoms are going to chiropractors for general checkups, and the chiropractors are “finding” specific things to treat. The total of the “per 100 encounters” column is 123.76 conditions treated, so if all 39 checkup encounters received no treatment, everyone else would have to be treated for 2 things.

I suggest that anyone consult the AHPRA report in detail before making too much of the “hangman’s fracture in a baby” case.

There are good reasons for doubt that the baby had such a fracture, also whether the chiropractic care (pointless as that may have been) was responsible for the somewhat vague changes in the baby’s condition. Mainly, the radiology is very dubious, and symptoms did not start until two days after treatment, which is not likely with such a traumatic event of this degree.

(The evidence for stroke after neck manipulation is more compelling and that can evolve over some days . I have no information as to whether that is a tenable explanation for such an event as this in babies.)

Did you realize I had already linked to the AHPRA report in my article? Did you read the link by Michael Vagg? Did you take into account the last radiology report showing a healing fracture superimposed on a spondylolysis? Do you have another explanation for the new calcification that was observed and interpreted as a healing fracture? Do you think the chiropractors’ explanation for the baby’s loss of head control (inexperienced people handling the baby at a party!) was more credible than an manipulation-induced injury? You say there are good reasons to doubt that the baby had a fracture, but aren’t there also good reasons to think he did? Do you disagree that anything we can say is mere speculation pending a resolution of the differences in interpretation by radiologists?

Harriet, you yourself have been appropriately uncommitted on the matter —–” we can only speculate —-” — , so I was stunned by the hostility of your reaction.

Of course your article was the source of the information I consulted — I just wanted to be sure the link showed up for people in my comment. I based my opinion on that and my own understanding of the difficulties of infantile anatomy and radiology and of certain clinical likelihoods, in trying understand what happened.

Even the four-month radiologist’s report, which contains the only radiological evidence that there “may” have been a unilateral skeletal injury at some point is less than definite. The “may” in the report becomes transformed into a “likely” in the report summary, which I don’t like when there is probably some pressure to find some mitigation of a previous serious radiological misdiagnosis of a full-blown Hangman’s fracture. Also a lot of things can change in a baby over four months. Apparently three previous CT scans did not show periosteal reaction or any other indications of severe trauma, which remains a challenge to that interpretation.

All we can say is that this is a possible chiropractic injury. There are plenty of other reasons for opposing chiropractic treatment of children.

I am a chiropractor. I deliver evidence based treatment (to the best of my ability). My qualifications are such that I can register as a chiropractor, not a physiotherapist, not a physical therapist. I am not allowed to call myself a physiotherapist. If I want to be a physio/PT, I will have to do additional training, most likely an additional 3-4 years.

I would be happy to see a new career path develop for chiros who want to deliver evidence-based treatments under a new name, perhaps with a short training/qualification process. Have you “reform” chiropractors offered any helpful suggestions in that direction?

The comments on the baby incident are well written. There were conflicting radiologists reports and a radiologists final review at 12 months used by AHPRA/CBA that didn’t seem to include the all important CT at 6 months. It only reviewed the initial xray, CT and MRI and follow up CT at 3 months. The whole lot should have been reviewed by an independent paediatric radiologist to put the outcome/decision beyond reasonable doubt. An unresolved mess that the CAA has not helped.
The COAST review is a good start but it is a small cohort in Melbourne. The medical BEACH study has 1.5 million patients over many years. The study needs to be expanded to rural and interstate and be ongoing. It also left many questions unanswered as Harriet Hall has noted. It stated 46% treatment for Back Problems, yet back syndrome with radiating pain, “other,” sprains and strains, nerve-related problem, bursitis/tendinitis/synovitis, kyphosis/scoliosis, etc relate to the back but are not made clear. The 10% non-musculoskeletal problems needs more specifics otherwise it is left to conjecture.
The reference to the use of Activators is interesting as few chiro’s I know follow pure Activator Methods in its use. I use it as a gentle alternative for manipulation/mobilising only. Further investigation into the way it is utilized is needed.
As for the references to chiropractic in the USA, just like in medicine, the US has the best and absolute worst of both of our professions. Many things done there are banned here.
The medical profession has a culture of critical self examination and evaluation that leads to reform and change, that is progress. Chiropractic needs this. If as a chiropractor I criticise, I get shouted down by the subluxation true believers, or as one recently said in a Podcast “the loudest voice wins!” Facepalm!
I have spent 20+ years developing the trust of my local doctors and I was invited several years ago to join some in practice. I now work in a medical centre and 80% of my new patients are medical referrals (Pity the COAST study didn’t use me. I’m medically biased). If I practiced any WOO or BS my doctors would cut me off at the knees instantly. We communicate constantly and every day begins with a meeting over Cappuccino’s where we discuss specific patients, case studies, practice issues etc. The way to a doctors heart is an espresso machine and a great Cappuccino (I’m the barista). I market myself to my doctors as another approach available to them in the treatment of chronic spinal conditions. The Doctors I talk to are all well aware of the differences between chiro’s and the majority of older chiro’s I talk to get medical referrals. There needs to institutional change and this has already been happening for years at COCA, the CAA needs to catch up.
I appreciate the criticism from Harriet Hall, Mick Vagg, John Cummingham, Edzard Earnst et al. I believe it is already leading to change and progress.

Massage per se is a valuable intervention for dealing with muscle knots and other problems. Plus, it generally just feels nice. I highly recommend Paul Ingraham’s website (saveyourself.ca) for a scientific discussion of massage and a bunch of other scientific controversies regarding musculoskeletal health, plus tons o’ other interesting stuff. Great website.

Where massage comes into difficulties scientifically is all the crap that tends to accompany it – therapeutic touch, reiki, visceral manipulation, organ repositioning, craniosacral therapy, and the list goes on. A lot of credulous nonsense is taught in massage schools and continuing education courses.

So massage is fine, it’s a great way to address painful muscle knots, which can help with a lot of other problems (including horrific back pain). If they offer you anything but massage, look it up on quackwatch first, because there’s a good chance it’s utter nonsense.

Torticolis, whether adult or pediatric is still torticolis. What is torticolis ? It’s a spasmodic condition of the unilateral (anterior ) cervical musculature. Why then should a chiropractor intervene with spinal manipulation when clearly the pathology lies in the contractile/ spasmodic structures? Why manipulate and apply thrust to the cervical vertebrae when these innocent bystanders are pulled every which way by the SCM or possibly the scalenes. Here’s the answer…chiropractors are not trained in myofascial release or structural integration via fascial mobilization. They only manipulate bones….ONLY! I practice structural integration as well as Rolfing as a PT and the results I get using these principles continue to astound even my seasoned chiropractic physicians (yes, they come to me for treatment of their myofascial pain symptoms after all chiropractic interventions have been exhausted). They’re clueless when it comes to structural integration. They rely solely on high velocity thrust manipulation, gadgets that claim to relieve pain but they can never TREAT their patients to the point of pain resolution and discharge. Shame and sham ….that’s chiropractic in a sense.

@JJ
Your comments rank up there with some of the more stupid ones about chiropractic. BTW,this site has some less than favorable things to say about MFR and structural integration.
And the course instructors are more than happy to offer them to chiros. So your anecdotes about your local chiro visitors are just that. I could say the same things about many PTs.

The bias here is interesting. Writers here observe that one apporach (SMT) is no better than the other (medical=pharma) for low back pain, and clearly suggest that the far more risky pharma modality be employed. The evidence supports the reality that pretty much any drug presents substantially mor risk than low back SMT where the risk approaches 0. Yet where the literature does not support a known risk of >1:1M for neck SMT, there is hue-and-cry about the risk . (any assertion of greater risk is strictly anecdotal)
Perhaps the writers here ought to add “rational” to their “evidence based, scientific” arguments.

Note that all interventions are essentially equal over the course of weeks, including no treatment except routine activity.

Also note that the risk of cervical artery dissection is an estimate because chiropractors, the main group responsible for upper-neck adjustments, do not systematically track and report it. The estimates all come from emergency room visits, which undoubtedly underestimates the risk, probably by an order of magnitude.

Rather than pointing the finger at the imperfections of other types of treatments, why not suggest that spinal manipulation be systematically studied for safety and effectiveness? Why not be outraged that chiropractors make promises about effectiveness that they have no evidence for?

“Yet where the literature does not support a known risk of >1:1M for neck SMT, there is hue-and-cry about the risk .”

Adding to what WLU has said, I think the risk usually quoted by chiropractors is a risk per manipulation. The risk during a typical course of chiropractic treatment, or from “maintenance” treatment over some years will be much greater, in proportion with the number of manipulations.

Also, the reason SMT is not advisable as a routine treatment of musculoskeletal neck pain is that OTHER, PHYSICAL methods, not carrying the same risk, work about as well in the studies. They would be a better first choice.

NSAIDs are irrelevant to that question — they might be used as well, such as for pain relief.

Nevertheless, similar considerations almost certainly apply to some uses of NSAIDS. I have seen doctors use them unwisely. But that does not provide an escape clause for SMT, or justify the inclination of chiropractic to brush off the issue.

Yes, the chiros always bring up NSAIDs as if those were the only two choices, setting up a false dilemma. But it’s not just a choice between NSAIDs and multiple trips to a chiropractor’s office for SMT, and even if it were, many patients would prefer to stay home and take a pill, even knowing the risks. Others would prefer not to use any treatment but staying as active as they can tolerate until it goes away, which most back pain does reasonably soon anyway.

“Pmoran says:
December 11, 2013 at 4:47 pm
The risk during a typical course of chiropractic treatment, or from “maintenance” treatment over some years will be much greater, in proportion with the number of manipulations.”

Clearly Pmoran has no understanding about risk and probability. The probability of a coin toss is 50/50 regardless of the number of times it is tossed. Following his logic, the risk for medication would similarly increase with each pill swallowed. You can’t have it both ways,

“WilliamLawrenceUtridge says:
The estimates all come from emergency room visits, which undoubtedly underestimates the risk, probably by an order of magnitude.”

Again, the writer privileges himself with the use of conjecture while holding others to the requirement of scientific evidence. The fact of this matter is that there is absolutely no fact evidence in the literature that demonstrates that neck SMT is a precipitating factor in any kind of dissection or stroke. All that exists is an observed temporal relationship. The only science related to this temporal relationship is a study by Cassidy, Haldeman, et al that demonstrates that the chiropractic/stroke relationship is actually slightly lower than the temporal relationship to stroke after attending a family physician.
In fact, the only studies on neck artery stress induced by SMT have been done by Herzog, et all, at the University of Calgary. These studies suggest that SMT forces do not even approach the forces necessary to cause strain to the vert. art., let alone cause intimal injury.
If you insist on the science on these things, avail yourselves of it. The rhetoric, uninformed conjecture, and unbalanced accountabilities on this topic are becoming boring.

Clearly Pmoran has no understanding about risk and probability. The probability of a coin toss is 50/50 regardless of the number of times it is tossed. Following his logic, the risk for medication would similarly increase with each pill swallowed. You can’t have it both ways,

Clearly you are missing some reading comprehension. Yes, the risk of an individual manipulation is likely independent (although that is not actually established; it is conceivable that repeated “adjustments” could damage/weaken the tissues, bones, ligaments, etc slowly over time leading to increased risk of catastrophic injury later on. However, this is not established either and it seems more likely to me that you are correct, but be aware of the assumptions you are making and claiming to be definitive.)

The problem is that there is such a thing as cumulative risk. The more times you are exposed to something the more likely you are to experience it. If something has a 1% chance of happening, then by doing the adjustment 100 times you are very likely to have had it happen at least once.

It seems pmoran understands statistics just fine in this case. It is you that has some lack of understanding.

The difference between a chiropractor’s visit and a physicians visit is that a physician is likely to be visited by a patient who is already experiencing early symptoms of a stroke. The chiropractor is likely to be the cause of a stroke in an otherwise-healthy or symptomless patient. Doctors see patients when the patient is feeling ill. Chiropractors place so much emphasis on seeing patients who are well. Every week. For the rest of their lives.

As for the evidence, and its complications, may I present this, this, this, this and this. Also, might I suggest that rather than denying the event on the basis of evidence, chiropractors could address the issue squarely and honestly by setting up a systematic tracking system for adverse events and patient follow-up, publicly releasing the results on an annual basis? That seems a much more honest reaction, geared towards improving the safety of the profession, than denying there is any evidence of a problem and attacking anyone who suggests there might be.

Andrey Pavlov says:
December 12, 2013 at 10:29 pm
“The problem is that there is such a thing as cumulative risk. The more times you are exposed to something the more likely you are to experience it. If something has a 1% chance of happening, then by doing the adjustment 100 times you are very likely to have had it happen at least once.”

This would be true IF this was a matter of cumulative risk, which assertion you have no science to support.

Harriet Hall says:
December 13, 2013 at 12:23 pm
“It might be easier to understand in terms of coin flips. On each flip, the probability is 50/50; but if you flip 100 coins, you’ll get more instances of tails.”

Nonsense

WilliamLawrenceUtridge says:
December 13, 2013 at 11:53 am
“The difference between a chiropractor’s visit and a physicians visit is that a physician is likely to be visited by a patient who is already experiencing early symptoms of a stroke. The chiropractor is likely to be the cause of a stroke in an otherwise-healthy or symptomless patient. Doctors see patients when the patient is feeling ill. ”

Again, your statement is totally unfounded. It is based on speculation that would offend even you, if your assertions had been presented by someone else.

The more rational explanation is that the tpyical pre-stroke symptom constellation consists of severe neck pain and headache….. symptoms which typically take patients to the chiropractor.

“The problem is that there is such a thing as cumulative risk. The more times you are exposed to something the more likely you are to experience it. If something has a 1% chance of happening, then by doing the adjustment 100 times you are very likely to have had it happen at least once.”

This would be true IF this was a matter of cumulative risk, which assertion you have no science to support.

If there is a 1% chance of an adjustment causing a stroke, even without any relatedness in risk between each adjustment (i.e. each adjustment is a completely independent event, like a coin flip) then doing that adjustment 100 times means there is a high probability (close to 100%) that it would happen once in that set. Yes, it is correct that if it doesn’t happen by the 100th adjustment that doesn’t mean the next adjustment has a higher risk of stroke. But that doesn’t affect the fact that the law of large numbers means that unlikely events are almost certain to happen given enough trials.

Again, your statement is totally unfounded. It is based on speculation that would offend even you, if your assertions had been presented by someone else.

The more rational explanation is that the tpyical pre-stroke symptom constellation consists of severe neck pain and headache….. symptoms which typically take patients to the chiropractor.

Well, it seems the only way to resolve this would be some sort of study where the safety of cervical manipulation is systematically assessed. Have chiropractors done such a study? Doctors are expected to use interventions with a demonstrated record of safety, efficacy and clinical equipose. Why have chiropractors operated for over a century without discharging a similar ethical burden?

“Following his ((mine)) logic, the risk for medication would similarly increase with each pill swallowed. ”

Does it not, usually?

Others get the point, which I might have expressed better, that it is the risk TO each patient during programs of chiropractic management rather than the risk PER manipulation that we should be looking at. The tension headache patient who developed a stroke after her 11th cervical manipulation would look at it that way.

The Cassidy study is impossible to interpret. I have examined it many times and cannot see how it controls for patients with sudden,, uncharacteristic, occipital headaches, or headaches with associated neurological symptoms preferentially seeking MD attention. Can you explain that?

It also seems to confirm the high risk of stroke in young persons in association with neck manipulation. In any case, there have been many cases where stroke occurred without symptoms attributable to an incipient VAD, such as the one mentioned above.

I wonder as well – is there any indication that manipulation cumulatively increases risk? That each manipulation damages the arteries just a little bit, eventually culminating in a dissection? I realize it’s possible to have a single manipulation cause a stroke, but is there increased risk after each adjustment?

We don’t know if repeated manipulations increase the risk of stroke for subsequent manipulations. We do know that some patients tend to become “addicted” to manipulations, returning to their chiropractor at frequent intervals – but we don’t know whether this is psychological or physical. I have heard orthopedic surgeons speculate that repeatedly forcing a joint beyond its normal range might cause damage that would make it more likely to develop symptoms. Chiropractors have not done the necessary research to evaluate possible adverse side effects of their treatments.

As Dr. Hall said, to my knowledge there is no evidence of cumulative risk of adjustment as you state it. I think it is possible and probably happens in some subset of people getting adjustments, but that it is likely a small subset.

What I was referring to is the law of large numbers. Even an exceedingly rare complication will happen if you do it enough times to enough people. It makes sense that there would be a subset of the population that will never get a stroke from manipulation no matter how many times they are manipulated. But each manipulation will be slightly different, stressing different structures differently and as person’s physiology will change as they age which could make someone who wouldn’t have gotten a stroke have one. The point is that, on the whole, you will get VADs from adjustments as you do more and more adjustments.

DC in my area have now established themselves as post orthopedic surgery experts. This has been a real thorn to the PhD physical therapists who are consulted by the orthopedists who are bypassed by these DC’s and even charge less.

The PTs are fuming because the DC’s are not actually following prescriptive physician orders for therapy and will not confront the Chiropractors who are doing their thing as they see it.

DCs need to go back to finding subluxations of the spine on glass roentgrams that a fellowship trained radiologist with a $2 million CT cannot find. DC in my area keep me busy with compression fractures, pathologic fx and diagnosing plantar fascitis.